INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 28, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NASR Consultant Group, Incorporated was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on staff interviews and and a review of staff records conducted during the onsite inspection, the facility failed to ensure that all of the staff persons working for the facility obtained the required 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training.
Staff Person #2 was hired as a counselor assistant on 10/05/2015, and was required to have 6 hours of training in HIV/AIDS, and 4 hours of training in TB/STDs by 10/05/2016. The facility has no documentation of the staff person completing any training hours in HIV/AIDS or TB/STDs.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The in-completion of the required 6 hours of HIV/AIDS and 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training was reviewed with Staff Person #2 during a performance appraisal meeting on 1/11/2017.
Staff Person #2 will be scheduled for HIV/AIDS and TB/STD training as soon as possible.
Ongoing, Facility Director will review Monthly Training reports with each counselor during scheduled supervision to ensure training requirements are being met. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document all of the required information in its fire drill records.
There are only two exits for the facility, both of which are stairways. All of the fire drill logs from 01/15/2016, through 11/18/2016, list,"Stairway" as the exit route used.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Effective immediately, fire drill logs will specify which stairway was used during fire drills by indicating either "Near Stairway" or "Far Stairway."
The Facility Director will review these changes during Staff Meeting on January 25th, 2017. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on staff interviews and a review of the facility's fire drill record conducted during the onsite inspection, the facility failed to use alternate exits during fire drills.
There are only two exits for the facility, both of which are stairways. The back stairway was the only exit route that was used for all fire drills conducted from 01/15/2016, through 11/18/2016.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Effective immediately, fire drills will be conducted using alternative routes. The routes will be identified as "Near Stairway" or "Far Stairway."
The Facility Director will review these changes during Staff Meeting on January 25th, 2017.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records conducted during the onsite inspection, the facility failed to update client treatment plans at least every 60 days in 1 of 3 applicable client records reviewed.
Client #6 was admitted for treatment on 03/01/2016, and discharged on 07/24/2016. The client's individualized treatment plan was completed on 03/07/2016, but there were no documented treatment plan updates completed prior to the client's discharge.
These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
Facility Director will review policy and procedures of treatment plan updates with all staff during clinical staff meeting 1/25/2017.
Facility Director will ensure that treatment plans are being completed in the appropriate time frames during monthly chart audits.
Chart audits will be conducted on a monthly basis and outcomes reviewed with clinical staff during scheduled supervision. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records conducted during the onsite inspection, the facility failed to document a complete client record in 3 of 8 client records reviewed.
Client #5 was admitted for treatment on 03/17/2016, and was discharged on 05/24/2016, but the client's record did not have a documented case consultation.
Client #6 was admitted for treatment on 03/01/2016, and was discharged on 07/24/2016, but the client's record did not have a documented case consultation.
Client #7 was admitted for treatment on 04/25/2016, and was discharged on 08/31/2016, but the client's record did not have a documented case consultation.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Facility Director will review policy and procedures for case consultations with all staff during staff meeting on 1/25/2017.
Effective immediately, each client's progress should be reviewed at least quarterly during a case conference that should at least include primary counselor and one other clinician.
The Facility Director will insure that case consultations are completed by conducting chart audits.
Chart audits will be conducted on a monthly basis and outcomes reviewed with clinicians during clinical supervision as scheduled.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual) for all client's whose treatment was being reimbursed through medical assistance.
Client #3, a client whose treatment was being funded through medical assistance, was admitted for treatment on 06/22/2016, and was an active client at the time of the onsite inspection. The client's individualized treatment plan dated 06/29/2016, was not signed by a physician.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Client #3's treatment plan will be signed by the Medical Director (Physician) by 1/23/2017.
Chart audits will be conducted on a monthly basis by the Facility Director; who will ensure clinicians acquired the physician's signature for treatment plans of medicaid funded clients. |